Form 27.1 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Brief Infant Toddler Social Emotional Assessment (BITSEA™) SAQ, Phase 2g

OMB Specification

Brief Infant Toddler Social Emotional Assessment (BITSEA™) SAQ

Event Category:	Time-Based
Event:	12M, 30M
Administration:	N/A
Instrument Target:	Child
Instrument Respondent:	Primary Caregiver
Domain:	Neuro-Psychosocial
Document Category:	Scored Assessment
Method:	Self-Administered
Mode (for this instrument*):	In-Person, PAPI
OMB Approved Modes:	In-Person, PAPI; Phone, PAPI
Estimated Administration Time:	9 minutes
Multiple Child/Sibling Consideration:	Per Child
Special Considerations:	N/A
Version:	2.0
MDES Release:	4.0

*This instrument is OMB-approved for multi-mode administration but this version of the instrument is designed for administration in this/these mode(s) only.

Copyright © 2006 by Yale University and the University of Massachusetts.  All rights reserved.  Published and distributed exclusively by NCS Pearson, Inc. Normative data copyright © 2006 by Yale University and the University of Massachusetts.

This page intentionally left blank.

Brief Infant Toddler Social Emotional Assessment (BITSEA™) SAQ

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

BITSEA SAQ SPECIFICATIONS 3

FOR OFFICE USE ONLY: 15

This page intentionally left blank.

Brief Infant Toddler Social Emotional Assessment (BITSEA™) SAQ

GENERAL PROGRAMMER INSTRUCTIONS:

WHEN PROGRAMMING INSTRUMENTS, VALIDATE FIELD LENGTHS AND TYPES AGAINST THE MDES TO ENSURE DATA COLLECTION RESPONSES DO NOT EXCEED THOSE OF THE MDES. SOME GENERAL ITEM LIMITS USED ARE AS FOLLOWS:

DATA ELEMENT FIELDS	MAXIMUM CHARACTERS PERMITTED	DATA TYPE	PROGRAMMER INSTRUCTIONS
ADDRESS AND EMAIL FIELDS	100	CHARACTER
UNIT AND PHONE FIELDS	10	CHARACTER
_OTH AND COMMENT FIELDS	255	CHARACTER	Limit text to 255 characters
FIRST NAME AND LAST NAME	30	CHARACTER	Limit text to 30 characters
ALL ID FIELDS	36	CHARACTER
ZIP CODE	5	NUMERIC
ZIP CODE LAST FOUR	4	NUMERIC
CITY	50	CHARACTER
DOB AND ALL OTHER DATE FIELDS (E.G., DT, DATE, ETC.)	10	NUMERIC CHARACTER	DISPLAY AS MM/DD/YYYY STORE AS YYYY-MM-DD HARD EDITS: MM MUST EQUAL 01 TO 12 DD MUST EQUAL 01 TO 31 YYYY MUST BE BETWEEN 1900 AND CURRENT YEAR.
TIME VARIABLES	TWO-DIGIT HOUR AND TWO-DIGIT MINUTE, AM/PM DESIGNATION	NUMERIC	HARD EDITS: HOURS MUST BE BETWEEN 00 AND 12; MINUTES MUST BE BETWEEN 00 AND 59

Instrument Guidelines for Participant and Respondent IDs:

PRENATALLY, THE P_ID IN THE MDES HEADER IS THAT OF THE PARTICIPANT (E.G. THE NON-PREGNANT WOMAN, PREGNANT WOMAN, OR THE FATHER).

POSTNATALLY, A RESPONDENT ID WILL BE USED IN ADDITION TO THE PARTICIPANT ID BECAUSE SOMEBODY OTHER THAN THE PARTICIPANT MAY BE COMPLETING THE INTERVIEW. FOR EXAMPLE, THE PARTICIPANT MAY BE THE CHILD AND THE RESPONDENT MAY BE THE MOTHER, FATHER, OR ANOTHER CAREGIVER. THEREFORE, MDES VERSION 2.2 AND ALL FUTURE VERSIONS CONTAIN A R_P_ID (RESPONDENT PARTICIPANT ID) HEADER FIELD FOR EACH POST-BIRTH INSTRUMENT. THIS WILL ALLOW ROCs TO INDICATE WHETHER THE RESPONDENT IS SOMEBODY OTHER THAN THE PARTICIPANT ABOUT WHOM THE QUESTIONS ARE BEING ASKED.

A REMINDER:

ALL RESPONDENTS MUST BE CONSENTED AND HAVE RECORDS IN THE PERSON, PARTICIPANT, PARTICIPANT_CONSENT AND LINK_PERSON_PARTICIPANT TABLES, WHICH CAN BE PRELOADED INTO EACH INSTRUMENT. ADDITIONALLY, IN POST-BIRTH QUESTIONNAIRES WHERE THERE IS THE ABILITY TO LOOP THROUGH A SET OF QUESTIONS FOR MULTIPLE CHILDREN, IT IS IMPORTANT TO CAPTURE AND STORE THE CORRECT CHILD P_ID ALONG WITH THE LOOP INFORMATION. IN THE MDES VARIABLE LABEL/DEFINITION COLUMN, THIS IS INDICATED AS FOLLOWS: EXTERNAL IDENTIFIER: PARTICIPANT ID FOR CHILD DETAIL.

BITSEA SAQ SPECIFICATIONS

BSS10000. Child's name: ____________________________________________

BSS12000/(BITSEA_DATE_COMP). Date of test  |___|___| / |___|___|  / |___|___|___|___|

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS13000/(BITSEA_PREMATURE). Was your child born prematurely?

Label	Code	Go To
Yes	1
No	2	BSS13100

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS13010/(BITSEA_EXPECTED_DOB). If yes, what was the expected date of birth  |___|___| / |___|___|  / |___|___|___|___|

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS13100. Many statements describe normal feelings and behaviors, but some describe feelings and behaviors that may be problems. Please do your best to respond to every item. Please circle the ONE response that best describes your child's behavior in the LAST MONTH.

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS14000/(BITSEA_SUCCEED). Shows pleasure when he or she succeeds (for example, claps for self).

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS15000/(BITSEA_HURT_OFTEN). Gets hurt so often that you can't take your eyes off him or her.

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS16000/(BITSEA_TENSE). Seems nervous, tense, or fearful.

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS17000/(BITSEA_RESTLESS). Is restless and can't sit still.

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS18000/(BITSEA_FLW_RULES). Follows rules.

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS19000/(BITSEA_WAKES_NIGHT). Wakes up at night and needs help to fall asleep again.

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS20000/(BITSEA_TANTRUM). Cries or has a tantrum until he or she is exhausted.

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS21000/(BITSEA_AFRAID). Is afraid of certain places, animals or things.

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS22000/(BITSEA_LESS_FUN). Has less fun than other children.

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS23000/(BITSEA_LOOKS_UPSET). Looks for you (or other parent) when upset.

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS24000/(BITSEA_CRIES_LEAVE). Cries or hangs onto you when you try to leave.

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS25000/(BITSEA_SERIOUS). Worries a lot or is very serious.

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS26000/(BITSEA_LOOKS_NAME). Looks right at you when you say his or her name.

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS27000/(BITSEA_NO_REACT). Does not react when hurt.

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS28000/(BITSEA_AFFECTIONATE). Is affectionate with loved ones.

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS29000/(BITSEA_NO_TOUCH). Won't touch some objects because of how they feel.

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS30000/(BITSEA_SLP_TROUBLE). Has trouble falling asleep or staying asleep.

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS31000/(BITSEA_RUNAWAY). Runs away in public places.

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS32000/(BITSEA_PLAY_OTHERS). Plays well with other children (not including brother/sister). 

PARTICIPANT INSTRUCTIONS

• Circle Not Applicable if there is no contact with other children

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2
Not Applicable	-7

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS33000/(BITSEA_PAY_ATTN). Can pay attention for a long time (other than when watching TV).

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS34000/(BITSEA_ADJCHANGE). Has trouble adjusting to changes.

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS35000/(BITSEA_HURT_HELP). Tries to help when someone is hurt (for example, gives a toy).

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS36000/(BITSEA_OFTEN_UPSET). Often gets very upset.

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS37000/(BITSEA_GAGS_FOOD). Gags or chokes on food.

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS38000/(BITSEA_IMITATE). Imitates playful sounds when you ask him or her to.

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS39000/(BITSEA_REFUSE_EAT). Refuses to eat.

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS40000/(BITSEA_HITS_OTHERS). Hits, shoves, kicks, or bites children (not including brother/sister).

PARTICIPANT INSTRUCTIONS

• Circle Not Applicable if there is no contact with other children

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2
Not Applicable	-7

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS41000/(BITSEA_DESTRUCTIVE). Is destructive. Breaks or ruins things on purpose.

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS42000/(BITSEA_POINT_FAR). Points to show you something far away.

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS43000/(BITSEA_HIT_PARENT). Hits, bites or kicks you (or other parent).

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS44000/(BITSEA_HUG_DOLL). Hugs or feeds dolls or stuffed animals.

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS45000/(BITSEA_UNHAPPY). Seems very unhappy, sad, depressed, or withdrawn.

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS46000/(BITSEA_HURT_PARENT). Purposely tries to hurt you (or other parent).

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS47000/(BITSEA_FREEZE_UPSET). When upset, get very still, freezes, or doesn't move.

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS47100. The following statements describe feelings and behaviors that can be problems for young children.  Some of the descriptions may be a bit hard to understand, especially if you have not seen the behavior in your child.  Please do your best to respond to all statements.  Please circle the ONE response that best describes your child’s behavior in the LAST MONTH.

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS48000/(BITSEA_SPECIAL_ORDER). Puts things in a special order over and over and gets upset if he or she is interrupted.

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS49000/(BITSEA_REPEAT_ACTION). Repeats the same action or phrase over and over without enjoyment. 

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS50000/(BITSEA_REPEAT_MOVEMENT). Repeats a particular movement over and over (like rocking, spinning). 

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS51000/(BITSEA_UNAWARE). Spaces out. Is totally unaware of what's happening around him or her.

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS52000/(BITSEA_NO_EYE). Does not make eye contact.

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS53000/(BITSEA_NO_PHYSICAL). Avoids physical contact.

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS54000/(BITSEA_HURTS_SELF). Hurts self on purpose (for example, bangs his or her head).

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS55000/(BITSEA_NOT_EDIBLE). Eats or drinks things that are not edible (like paper or paint). 

Label	Code	Go To
Not true/Rarely	0
Somewhat true/Sometimes	1
Very true/Often	2

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS56000/(BITSEA_WORRY_BEHAVE). How worried are you about your child's behavior, emotions, or relationships?

Label	Code	Go To
Not at all worried	1
A little worried	2
Worried	3
Very worried	4

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

BSS57000/(BITSEA_WORRY_LANG). How worried are you about your child's language development?

Label	Code	Go To
Not at all worried	1
A little worried	2
Worried	3
Very worried	4

SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.

FOR OFFICE USE ONLY:

FOU01000/(P_ID). Child's Participant ID: ______________________________________

FOU02000/(R_P_ID). Parent/Caregiver ID: __________________________________

Public reporting burden for this collection of information is estimated to average 9 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593*). Do not return the completed form to this address.